Probably the medical professional who is closer to the daily life of an athlete, who participates regularly in competitions, whether or not high-performance, is the expert in exercise and sports medicine. However, occasionally the athlete may need to resort to other medical professionals, for various reasons, such as a general practitioner, a dermatologist, a cardiologist, an orthopedist or a gastroenterologist. Therefore, every physician is subject to come across a patient who is an intermediate level or high-performance athlete, and will need to go through doping controls throughout his sporting life. The purpose of this article is to provide concepts and information to medical professionals so that they can properly treat their "athlete patients", avoiding the use of substances that may harm them in a doping control situation.
History
In the past, the list of banned substances was drawn up by the Medical Commission of the International Olympic Committee (IOC) and usually revised in the year previous to an Olympic game. The IOC list was used by international federations of different sports, in many countries. However, over time, alternative lists slightly different from each other were created. This would compel the experts in exercise and sports medicine to know which authority was responsible for a given competition, and what the list of banned substances adopted would be. The problem was finally resolved with the creation in 1999 of the World Anti-Doping Agency, also known as WADA.
WADA annually updates the list of prohibited substances and methods. The list is valid from January 1 of each year and is usually updated and approved by WADA Executive Committee in the last quarter of the preceding year, then published on WADA's website: www.wada-ama.org.
Concept of doping
The concept of doping by WADA is based on three criteria: enhancement of sports performance; risk to the health of the athlete; and that use of the substance or method violates the spirit of sport. When two of these three criteria are present in a substance or a method, the theoretical possibility of listing occurs.
Examples of artificial performance enhancement include anabolic steroids, which also cause serious risks to the health of the athlete. This group of substances includes two of the three basic principles of the concept of doping, and therefore makes the list.
The concept of "violating the spirit of sport" can give rise to subjective interpretations, but these values are explained in WADA World Anti-Doping Code as follows: ethics, fair play and honesty; health; excellence in performance; character and education; fun and joy; team spirit; dedication and commitment; respect for rules and laws; self-respect and respect for the other athletes; courage; solidarity.
Cannabinoids, such as hashish and marijuana, are examples of substances considered doping because they are harmful to the health of the athlete and contrary to the fundamental values of sport, although they not enhance athletic performance.
Definition of doping
By resolution of the World Anti-Doping Code, doping is characterized when there is/are one or more anti-doping rule violations, which are as follows:
1. Presence of a prohibited substance or its metabolites or markers in the sample collected from an athlete;
2. Use or attempted use by an athlete of a prohibited substance or prohibited method;
3. Refusing or failing without compelling justification to submit to sample collection after notification, or otherwise evading doping control;
4. Violation of the requirements regarding athlete availability for out-of-competition testing;
5. Tampering or attempted tampering with any part of doping control;
6. Possession of prohibited substances and prohibited methods;
7. Trafficking or attempted trafficking of prohibited substances and prohibited methods;
8. Administration or attempted administration to any athlete in-competition of a prohibited substance or a prohibited method; or administration or attempted administration to any athlete out-of-competition of a substance or method that is prohibited out-of-competition;
9. Assisting, encouraging, aiding, abetting, conspiring, covering up or any other type of intentional complicity involving an anti-doping rule violation;
Types of doping control
In-competition control is performed in a specific competition, such as a soccer game or a swimming competition. In this type of control, all WADA-prohibited substances and methods are considered doping.
The out-of-competition control can be performed at the discretion of International Federations, National Olympic Committees or National Anti-doping Agencies, which have a database on the location of athletes, updated periodically. An athlete may receive a visit from an anti-doping control officer at any time, at home, at the training facilities, at the workplace or during holidays. In principle, this type of control can be performed up to 48 hours before a sporting competition.
WADA list of prohibited substances and methods
As mentioned above, the list of prohibited substances and methods is annually updated by WADA, always in the last quarter of the year, coming into force on January 1 of the following year and being valid until December 31 of that year.
The following tables show the prohibited substances and methods, as updated by WADA for the year of 2016. Table 1 shows the list of prohibited substances and methods in any in- and out-of-competition testing. Table 2 shows the list of prohibited substances and methods for in-competition testing only. Table 3 shows the list of prohibited substances in particular sports. The Tables display the most common substances in each category. The complete list can be found in English on WADA website (www.wada-ama.org) or in Portuguese, on the website of the Brazilian Doping Control Authority ( Autoridade Brasileira de Controle de Dopagem - ABCD): www.abcd.gov.br.
Authorization for therapeutic use
An athlete can use any substance that is part of WADA list for medical treatment, after requesting and being granted a therapeutic use exemption (TUE) to/by the competent body. It is also necessary that each of the following situations is covered:
a. That the prohibited substance is necessary to treat an acute or chronic medical condition, so that the suspension or non-use of the substance significantly worsens the symptoms;
b. The prohibited substance being claimed for use cannot enhance the physical performance beyond what would be expected with the simple treatment and reestablishment of the normal state of the athlete's health;
c. There are no other evidence-based alternatives to the use of the prohibited substance, or - in other words - that the prohibited substance is considered irreplaceable in the treatment of the athlete's medical condition;
d. That the need for the use of the prohibited substance does not result from previous non-therapeutic use of any substance or method banned by WADA.
World-class athletes and athletes who participate in an international competition should apply for TUE directly from the international federation for their sport. Athletes who participate in national competitions, in turn, must request a TUE directly from the ABCD, as soon as possible and within a period not less than 30 days before the competition. In Brazil, applications should be completed by the athlete and his/her assisting physician (form available on the ABCD website). Assessment is made by the ABCD TUE Commission (CAUT-ABCD); if the CAUT-ABCD considers that the use of the substance meets the criteria defined by the International Standard for Therapeutic Use Exemptions, the TUE is granted. Evidently, the form must be accompanied by appropriate documentation confirming the diagnosis, including results and expert opinion reports of the relevant complementary tests.
If due to a medical emergency a medical doctor has to administer a prohibited substance, the case must be reported as soon as possible to the ABCD using the TUE request system, available from www.abcd.gov.br. Documents proving admission to the emergency room and a clinical report of the emergency should also be sent. The request for therapeutic use of a prohibited substance with retroactive approval is possible only in cases of emergency treatment due to acute medical conditions, or in exceptional situations where the sending of the request for therapeutic use prior to doping control is not possible.
Conclusion
One of the principles of doping control is to seek to ensure the maintenance of the athlete's health and fair play. We must remember that the athlete is responsible for all substances that may be found in his or her body. For this reason, we consider that all medical professionals, regardless of their specialty, should have - as part of their medical knowledge wealth - the domain of basic concepts of doping control, not only to provide the best therapeutic alternatives, but mostly to avoid iatrogenic events that can jeopardize the credibility and career of an athlete patient.
Publication Dates
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Publication in this collection
Mar-Apr 2016
